Statement of Changes in Beneficial Ownership (4)
16 11월 2018 - 7:47AM
Edgar (US Regulatory)
FORM 4
[ ]
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b).
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP OF SECURITIES
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OMB APPROVAL
OMB Number:
3235-0287
Estimated average burden
hours per response...
0.5
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Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934 or Section 30(h) of the Investment Company Act of 1940
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1. Name and Address of Reporting Person
*
Meeker Mary G
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2. Issuer Name
and
Ticker or Trading Symbol
Square, Inc.
[
SQ
]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
__
X
__ Director
_____ 10% Owner
_____ Officer (give title below)
_____ Other (specify below)
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(Last)
(First)
(Middle)
C/O KPCB, 2750 SAND HILL ROAD
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3. Date of Earliest Transaction
(MM/DD/YYYY)
11/13/2018
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(Street)
MENLO PARK, CA 94025
(City)
(State)
(Zip)
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4. If Amendment, Date Original Filed
(MM/DD/YYYY)
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6. Individual or Joint/Group Filing
(Check Applicable Line)
_
X
_ Form filed by One Reporting Person
___ Form filed by More than One Reporting Person
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Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned
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1.Title of Security
(Instr. 3)
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2. Trans. Date
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2A. Deemed Execution Date, if any
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3. Trans. Code
(Instr. 8)
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4. Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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5. Amount of Securities Beneficially Owned Following Reported Transaction(s)
(Instr. 3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr. 4)
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7. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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Amount
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(A) or (D)
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Price
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Class A Common Stock
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11/13/2018
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J
(1)
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626847
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D
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$0
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1253693
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I
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See Footnote
(2)
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Class A Common Stock
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11/13/2018
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J
(3)
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162050
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A
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$0
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230374
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I
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See Footnote
(4)
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Class A Common Stock
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11/13/2018
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J
(5)
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142801
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D
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$0
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87573
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I
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See Footnote
(4)
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Class A Common Stock
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11/13/2018
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J
(6)
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31060
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A
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$0
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44491
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I
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See Footnote
(7)
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Class A Common Stock
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11/13/2018
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J
(8)
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34419
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D
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$0
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10072
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I
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See Footnote
(7)
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Class A Common Stock
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11/13/2018
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J
(9)
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17455
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A
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$0
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291076
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D
(10)
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Table II - Derivative Securities Beneficially Owned (
e.g.
, puts, calls, warrants, options, convertible securities)
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1. Title of Derivate Security
(Instr. 3)
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2. Conversion or Exercise Price of Derivative Security
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3. Trans. Date
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3A. Deemed Execution Date, if any
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4. Trans. Code
(Instr. 8)
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5. Number of Derivative Securities Acquired (A) or Disposed of (D)
(Instr. 3, 4 and 5)
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6. Date Exercisable and Expiration Date
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7. Title and Amount of Securities Underlying Derivative Security
(Instr. 3 and 4)
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8. Price of Derivative Security
(Instr. 5)
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9. Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr. 4)
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10. Ownership Form of Derivative Security: Direct (D) or Indirect (I) (Instr. 4)
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11. Nature of Indirect Beneficial Ownership (Instr. 4)
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Code
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V
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(A)
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(D)
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Date Exercisable
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Expiration Date
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Title
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Amount or Number of Shares
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Explanation of Responses:
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(1)
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Represents a pro-rata in-kind distribution of Class A Common Stock of the Issuer by KPCB Digital Growth Fund, LLC ("KPCB Growth"), KPCB DGF Founders Fund, LLC ("KPCB FF"), and KPCB sFund, LLC ("KPCB sFund") without consideration to the respective members of each such entity (the "Fund Distribution").
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(2)
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KPCB Holdings, Inc., as nominee, holds the stock for the account of KPCB Growth, KPCB FF, and KPCB sFund. All shares are held for convenience in the name of "KPCB Holdings, Inc., as nominee" for the accounts of such entities who each exercise their own voting and dispositive power of such shares. The reporting person is a managing member of KPCB DGF Associates, LLC ("DGF Associates"), which is the managing member of KPCB Growth and KPCB FF. The reporting person may be deemed to share voting and investment power over the securities held by KPCB Growth, KPCB FF and sFund. The reporting person disclaims beneficial ownership over such securities except to the extent of her pecuniary interest therein, and the inclusion of these securities in this report shall not be deemed an admission of beneficial ownership of the reported securities for purposes of Section 16 or for any other purposes.
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(3)
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Represents a change in the form of ownership from indirect to direct by virtue of the receipt of shares from KPCB Growth in the Fund Distribution by KPCB Growth.
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(4)
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The shares are held directly by DGF Associates. The reporting person is a managing member of DGF Associates and may be deemed to share voting and investment power over the securities held by DGF Associates. The reporting person disclaims beneficial ownership over such securities except to the extent of her pecuniary interest therein, and the inclusion of these securities in this report shall not be deemed an admission of beneficial ownership of the reported securities for purposes of Section 16 or for any other purposes.
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(5)
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Represents a pro-rata in-kind distribution of Class A Common Stock of the Issuer by DGF Associates without consideration to its members (the "DGF Associates Distribution").
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(6)
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Represents a change in the form of ownership from indirect to direct by virtue of the receipt of shares from KPCB sFund in the Fund Distribution by KPCB sFund.
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(7)
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The shares are held directly by KPCB sFund Associates, LLC ("sFund Associates"). The reporting person is a member of sFund Associates and may be deemed to share voting and investment power over the securities held by sFund Associates. The reporting person disclaims beneficial ownership over such securities except to the extent of her pecuniary interest therein, and the inclusion of these securities in this report shall not be deemed an admission of beneficial ownership of the reported securities for purposes of Section 16 or for any other purposes.
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(8)
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Represents a pro-rata in-kind distribution of Class A Common Stock of the Issuer by sFund Associates without consideration to its members (the "sFund Associates Distribution").
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(9)
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Represents a change in the form of ownership from indirect to direct by virtue of the receipt of shares in the DGF Associates Distribution and the sFund Associates Distribution.
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(10)
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Shares are held directly by the reporting person.
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Reporting Owners
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Reporting Owner Name / Address
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Relationships
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Director
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10% Owner
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Officer
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Other
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Meeker Mary G
C/O KPCB
2750 SAND HILL ROAD
MENLO PARK, CA 94025
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X
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Signatures
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/s/ Susan Biglieri, Attorney-in-Fact
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11/15/2018
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**
Signature of Reporting Person
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Date
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.
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*
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If the form is filed by more than one reporting person,
see
Instruction 4(b)(v).
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**
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Intentional misstatements or omissions of facts constitute Federal Criminal Violations.
See
18 U.S.C. 1001 and 15 U.S.C. 78ff(a).
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Note:
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File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure.
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Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB control number.
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